INTRODUCTION

Cardiovascular risk management decisions are

totally based on the profile of cardiovascular risk

factors (CVRF).

They lead to determining total cardiovascular

risk as being the risk of fatal cardiovascular

events in a predefined period.

It is important to know not only the CVRF

number got by a person but also the magnitude of

each factor, both of which are proportional to

cardiovascular risk (CVR).

CVRF CLASSIFICATION

Major risk factors

(whose association with the risk of cardiovascular disease was highly significant)

WHO defined the major risk factors using 3 criteria:

1. high prevalence among population;

2. independent impact on the risk of coronary heart disease or stroke;

3. their treatment or supervision decrease risk.

• Contributing risk

factors (that increase

CV risk at a less

significant level).

CRF CLASSIFICATION

modifiable risk factors

(factors that can be

controlled by diet or

treatment, for example:

smoking, obesity,

dyslipidemia, diabetes,

hypertension)

• non-modifiable risk

factors (for example: age,

sex, height, heredity).

CRF CLASSIFICATION

classical risk factors

(proved by many social

studies to be correlated

with CV risk).

• new risk factors (there are

more recent studies for

them and they may be

involved in different parts

of physiopathogenic cycle,

for example: lipoprotein,

homocysteine ,

proinflammatory and

thrombotic factors).

AGE

Over 83% of the population affected by coronary

heart disease is over 65 years old.

For both sexes, the risk of CAD increases with

age.

It is considered that the age limit for the risk of

CVD is over 45 years for men and over 55 years

for women. With age, the female advantage of

low CVR before menopause is lost.

At older age, women with myocardial have a

lower survival than men.

One explanation is the fact that most CVRF have

a higher age rate (e.g.: hypertension,

dyslipidemia, obesity, diabetes).

SEX incidence is significantly lower at women than at men

before the age of 50, for middle-age people the risk is 2-5 times higher at men than at women.

A INTERHEART research showed that women usually have their first AMI 9 years later than men.

The men AMI at a younger age may be explained by higher levels of plasma lipids and smoking before 60. Especially that in most countries smoking is more common in males.

In the past estrogen was considered as protective factor for atherosclerosis at women, but random studies regarding the hormone replacement therapy led to reconsideration of relationship between estrogen and the risk of AMI. It is proved that estrogen has a positive effect on lipid profile and improves vascular function at women, but social studies have brought controversial results on vascular protection offered by hormone replacement therapy .

HEREDITY

Family backgroung is considered as CVRF

in case of premature CVD, (e.g. IMA) at

first degree relatives: males <55 years old,

females <65 years old.

Racial factor plays a great role along with

heredity. For example, African Americans

with more severe hypertension than

Caucasians have higher CVR.

These differences must be taken into

account in determining overall risk as

well.

OBESITY

Obesity is a major CVRF with increasing

prevalence in developed countries mainly

due to:

environmental and social factors,

peculiarities of diet,

sedentary way of life.

Obesity is more common among people

with low socioeconomic level, thus linking

to this psychosocial risk factors.

INDEXES OF OBESITY Index Definition Limită obezitate

Body mass index (BMI)

(kg / sq m)

Ratio of weight (in kg) and

square height (m) (G/ h

square)

IMC=25-29,9 kg/sq m -

overweight

IMC>30 kg/sq m - obesity

IMC>40 kg/sq m – lethal

obesity

Abdominal circumference

(cm)

Circumference measured

at the umbilicus and

halfway between costal

margin and iliac crest

NCEP: > 102 cm at men

and > 88 cm at women

IDF: >94 cm at men and >

80 cm at women

Waist circumference to hip

circumference ratio (waist

to hip ratio, WHR)

Ratio of the 2

circumferences reflects the

type of obesity

> 0.95 (M) and> 0.81 (W)

- CVR associated

moderately high

IDF - International Diabetes Federation; NCEP- National Cholesterol Education Program

OBESITY Several recent studies have shown obesity (measured by

BMI) as an independent predictor of CVR, especially for high values of BMI;

BMI limiting parameter explained by the fact that it does not reflect the distribution of body fat nor does it differentiate between muscle and fat.

As a result, other parameters such as waist circumference and hip circumference ratio in waist circumference were proposed (waist to hip ratio, WHRM).

Waist to hip circumference ratio is a derived parameter that reflects the abdominal fat in report to the general body size.

In the INTERHEART study, this ratio was correlated significantly and progressively with the risk of AMI.

"OBESITY PARADOX" described recently in several social studies

defined as a better short- and long-term

prognosis at overweight or obese patients.

There were launched some possible

explanations (better metabolic reserve,

protective effects of some cytokines

secreted by adipose tissue, lower renin

activity, etc.), but so far there is no unique

satisfactory physiopathological

explanation.

At present it is considered that efforts

related to maintaining normal body mass

index should be kept at population level.

NORMAL WEIGHT OBESITY defined by normal body mass index (BMI <25 kg / sqm)

and excess body fat.

Threshold value above which it is considered that body

adiposity is increased at these patients has not been

established, but the largest study published up to date

defines excess fat as follows:

fat over 23.1% of body weight at men

fat over 33.3% of body weight at women

Normal weight obesity is associated with:

cardiometabolic abnormalities such as

metabolic syndrome and its components,

proinflammatory status,

increased oxidative stress,

increased cardiovascular mortality in women.

SEDENTARISM Sedentarism is a growing problem in the developed world:

Over 60% of population does not meet the minimum requirement of 30 minutes of daily physical activity

quarter of population does not perform any physical activity during the week.

Inactivity is associated with an increase 1.5-2 of CVR in comparison with active people.

The INTERHEART study showed that exercise was a protective factor with an OR of 0.86 for AMI occurrence (95% confidence interval 0.76 to 0.97M).

The mechanisms by which physical activity plays a CV protective role are multiple:

maintaining an appropriate body weight

increase in HDL-cholesterol

lowering triglycerides

increase of insulin sensitivity

reducing blood pressure

improve the uptake of oxygen by the myocardium

Increase of coronary artery diameter.

SMOKING Smoking is a major risk factor for atherosclerotic disease

(coronary, carotid, peripheral), including passive smoking,

showing to increase RCV.

Risk stratification should be based on total consumption of

cigarettes (expressed for example as parcel number per

year)

Calculation method number of packets per year:

Number of packet/year = (packets smoked per day)

x (years as a smoker)

Number of packets/year = (number of cigarettes

smoked per day) × (years as a smoker) / 20

(1 packet- 20 cigarettes)

Example: a patient smoking 15 cigarettes / day for 40 years

has consumpted (15 times 40) / 20 = 30-year packets.

CV risk is even greater as smoking onset occurs before the

age of 15 years.

SMOKING

The mechanisms by which smoking increases the CVR are:

Increase of total cholesterol and decrease of HDL cholesterol

platelet and leukocyte activation

Increase of circular fybronogen

endothelial dysfunction as well as promoting crack

vulnerable plaques

Increase of heart rate and blood pressure

Arterial vesselconstruction (including coronary spasm)

effects of worsening myocardial ischemia due to carbon

monoxide.

Stopping smoking is an effective method to reduce the CVR.

CV risk of former smokers decreases rapidly, reaching in

about 3 years after stopping to the level of similar non-

smokers.

SMOKING

Quitting smoking is the most effective of all

preventive measures, the effect being

pronounced at patients with coronary artery

disease.

There is no age limit for the benefits of

quitting smoking.

Clear and strong urge for smoking cessation

is often decisive, especially when it happens

during an event procedure or during an

coronorian intervention, the patient being

very motivated when deciding to quit

smoking.

ALGORITHM FOR SMOKING CESSATION

ASSISTANCE

patient consumes tobacco

want to quit smoking now?

create motivation to quit

Yes

Yes

start your

therapy

No

No

No

prevent

relapse Maintain Abstinence

Ever smoked?

Yes

SMOKING

Drug therapy includes nicotine replacement therapy,

available in different forms (gum, patch, nasal spray

or inhalators, pills), being considered that they would

increase 50-70% withdrawal rate.

Some European countries have adopted legislative

measures banning smoking in public places,

estimating that more than 200 million European

citizens would benefit from this legislation.

After banning smoking in public places, several

countries have reported reduction of acute coronary

events (in Italy, 11.2% in people between 35-64 years

and 7.9% for those between 65 and 74 years) .

ALCOHOL

Link between alcohol and CVR is more complex.

CVR is high for intensive consumers

CVR is lower for moderate drinkers compared to

abstainers.

Thus it is known that excessive alcohol consumption

(> 90g per day for at least 5 years) is a risk factor for

the development of dilated cardiomyopathy (DCM),

the cause of over a quarter of cases of CMD.

Also, excessive alcohol consumption increases the risk

of hypertension and, in parallel, the risk of

hemorrhagic stroke or subarachnoid hemorrhage.

Drinking large amounts of alcohol can lead to

particularly supraventricular arrhythmias (e.g. atrial

fibrillation in the so-called ,,Haliday-heart

syndrome,,).

ALCOHOL

On the other hand, all recent epidemiological

studies agree that moderate alcohol

consumption appears to have a protective CV

effect with evidence collected especially for red

wine.

In this kind of alcohol,the effects of

polyphenols contained in wine are more

beneficial than the effects of ethanol contained

in it.

However, it is proved that considering the

absence (and ethical difficulties) of average

studies, patients can not be advised to use

moderate amount of alcohol in order to reduce

CVR.

HIGH BLOOD PRESSURE

High blood pressure defined as values of blood pressure

over 140/90 mmHg, is one of the most important preventive

causes of cardiovascular death, contributing to about half of

the global CV mortality.

Cardiovascular mortality doubles for every 10 mmHg

increase in diastolic blood pressure and with 20 mmHg

systolic blood pressure.

Not only the absolute values of blood pressure are

cardiovascular risk factors, but the pulse pressure (the

difference between systolic blood pressure and diastolic

blood pressure), whose increase reflects the presence of a

predominant systolic high blood pressure, represents an

independent factory of risk for the cardiovascular mortality

(in particular coronary and for cardiovascular accidents )

especially after 55 years.

HIGH BLOOD PRESSURE

In consequence, the decrease in blood pressure values through measures of lifestyle modification and pharmacological treatment has a very important impact on reducing cardiovascular mortality in primary prevention.

Of lifestyle measures remain essential :

hyposalted diet

dropping weight

moderating alcohol consumption for consumers of ethanol

At these it should be added pharmacological measures for obtaining the normal values of blood pressure.

And in secondary prevention, it is proven that an optimal control of the blood pressure values significantly decreases the risk of relapse of ischemic cardiovascular accident, cardiovascular mortality after coronary accident.

DYSLIPIDEMIA

Dyslipidemia is one of the factors with high

prevalence and susceptibility to be modified.

It includes a series of disorders of lipid

metabolism with the potential of inducing and

maintenance of aterosclerotic phenomenon:

Classic anomalies ( increase of total cholesterol,

LDL cholesterol and decrease of HDL cholesterol)

Items recently described of the lipid imbalance

(apolipoproteins changes, the increasing number

of small dense LDL particles, of lipoproteins (a),

triglyceride-rich lipoproteins and their

fragments)

TOTAL CHOLESTEROL

Epidemiological studies ( Framingham studies,

Multiple Risk Factor Intervention Trial - MRFIT,

Atherosclerosis Risk In Communities - ARIC etc.)

have proved to be a direct relationship between

the serum levels of total cholesterol and

cardiovascular mortality and morbidity.

Cardiovascular risk increases by 2-3% for each

percentage point of total cholesterol

concentration.

Clinical trials that have used hypolipomiant

therapies have shown that reduction of colesterol

values joins morbidity and mortality reduction in

cardiovascular diseases in patients with or

without established cardiovascular disease.

LDL-CHOLESTEROL

Numerous clinical studies have shown that lowering

serum values of LDL cholesterol is associated with

decreased cardiovascular risk.

It has been proven that in order to reduce to 30 mg/dl

in plasmatic LDL cholesterol register a 30%

reduction of cardiovascular risk.

As a result, the reduction in serum concentration of

LDL cholesterol is the next target of therapy in people

with dyslipidemia, causing marked reduction in the

risk of coronary death, nonfatal myocardial infarction,

revascularization procedures and strokes.

The national guide Cholesterol Education Program

(NCEP) established in patients with cardiovascular

disease targets of LDL cholesterol concentration <

100 mg/dl or even < 70 mg/dl.

HDL CHOLESTEROL

Unlike LDL, increased HDL cholesterol level is a

cardiovascular protective factor.

This inverse relationship between HDL levels and

cardiovascular risk is explained by the role of HDL

cholesterol reverse transport that is mobilized from the

periphery to be catabolized in the liver, and involvement

in other antiaterogenic mechanisms.

antioxidant function

improvement of the inflammatory cascade

protection against procoagulant activity

The value of serum HDL cholesterol less than 40 mg/dl is

a predictive factor for cardiovascular disease.

Low HDL levels along with trygleceridemia are the

elements of the metabolic syndrome.

DIABETES MELLITUS

Insulin resistance, hyperinsulin and hyperglycemia are associated pathophysiological with atherosclerotic cardiovascular disease.

The diabetes have a higher risk of myocardial infarction or cardiovascular accident of 2-3 times, independent of other cardiovascular risk factors .

NCEP included in 2002 as a equivalent of BCI with a high risk.

Control of risk factors as well as glycemic values must be aggressive in patients with diabetes mellitus (LDl cholesterol values < 100 mg/dl and the optimal values of blood pressure of <130/80 mmHg ).

Optimal control of diabetes leads to lowering the rate of cardiovascular complications.

PSYCHOSOCIAL FACTORS

Includes:

Professional or personal stress

financial stress

stressful life events

depression

the perception of skill to control the situations of life

lack of social support

results of the study have shown that psychosocial factors can contribute in a significant proportion to lower risk of myocardial infarction.

their overall effect was smaller than the smoking, but comparable with hypertension or abdominal obesity.

the effect of stress on the risk of myocardial infarction was similar in men and women, age boundary and in all regions.

HOMOCYSTEINE

The first Association of increased serum homocysteine

concentration (Hcys) and atherosclerosis was based on necroptic studies in patients with the homozygot deficiency of enzymes necessary in homocysteine metabolism ( CBS, metilentetrahidrofolat reductase, MTHFR).

In patients with these defects, severe atherosclerosis develops from childhood and many of them shows a first myocardial infarction before the age of 20 years.

Homocysteine has toxic effects on the endothelium, is protrombotic, increases the synthesis of collagen and decreases nitric oxide availability.

Depending on the lab, hyperhomocystein is defined by a level of Hcys over 12-16 mmol/l. a level of 15-100 mmol/l is considered to be moderately increased, and more than 100 mmol/l is severely increased.

HOMOCYSTEINE

The main cause of hyperhomocysteinemia

remains the genetic one.

Main mutations found in the population are

mutations of the MTHFR gene, type C677T

and A1298C type.

These patients have an increased

atherosclerotic risk to the coronary artery,

peripheral and cerebral.

Blood concentration can be reduced to normal

through treatment with folic acid, but are

still needed studies to determine if this

treatment prevents the progression and

eventually the regression of atherosclerotic

lesions.

LIPOPROTEIN (A)

The lipoprotein (a) is a particle containing an ester of

cholesterol and apolipoprotein B100, differing of LDl

cholesterol by the presence of glycoprotein apo (a), a

plasminogen analog.

Studies in vitro and in vivo have shown that favors

atherogenesis and thrombogenesis, representing a

cardiovascular risk factor independently moderated.

A metaanalyse including 31 prospective studies reported a

relative risk of 1.5 times in patients with values of Lp (a)

in the upper third in comparation with lower distribution

Lp (a) (according to the averages in those categories of 50

versus 5 mg/dl)

The coexistence of an increased level of LDL, decreased of

HDL or the high blood pressure increases secondary the

cardiovascular risk in the patients with a high level of Lp

(a).

PROTHROMBOTIC FACTORS

Thrombosis plays a central role in the pathogenesis of acute coronary syndromes, through processes that involve both platelets and clotting factors.

An important haemostatic factor associated with the risk of major coronary ischemic is Fibrinogen. Thus, the high level of fibrinogen is associated with cardiovascular risk independent of lipid profile.

Other haemostatic factors correlated with increased cardiovascular risk are :

activated factor VII

Plasminogen activator inhibitor-1

Plasminogen Activator Tissue

Von Willebrand (that is a marker of endothelial dysfunction )

Relatively common genetic defects in population leading to a procoagulant potential are known as thrombophilias (factor V Leiden mutation, prothrombin -factor II mutation, deficits of protein C, S or antithrombin III)

Indications for setting completely thrombophilic profile :

in case of the disease at young age (below 45)

of his family agregation

CARDIOVASCULAR RISK SCORES

Estimation of the effect of combined

cardiovascular risk factors on

cardiovascular morbidity require the

use of risk scores, in which the major

risk factors to be included on the

basis of their weighted prognostics.

FRAMINGHAM SCORE

Framingham score is calculated on the basis of

equations that take into account gender, age, total

cholesterol, HDL cholesterol, smoking and systolic blood

pressure, assigning a number of points depending on

the presence and magnitude of each factor.

A form easier to use in actual practice is derived from

this score as a coronary risk map (Coronary Risk

Chart).

In order to evaluate the risk of cardiovascular morbidity

and mortality, the score set arbitrary limits :

<10% for low risk

10-20% for intermediate risk

>20% for high risk, that requires pharmacological

intervention.

THE SCORE SCORE

Unlike Framingham score:

report on cardiovascular mortality and not on

total cardiovascular events.

are taken into account and the deaths by

atherosclerosis in non-coronary territories

(AVC)

the score is adjusted average ages, changing

risk with age is more steep

there are separate scores for European

countries with high risk and low risk, where

there was complete data about mortality.

THE SCORE SCORE

The score is available in two

versions, one for the regions with low

risk (Belgium, France, Greece, Italy,

Spain, Luxemberg, Switzerland and

Portugal) and another for those at

high risk, where fit and our country,

along with other European countries

which were not mentioned in the list

above.

THE SCORE SCORE

It should be noted that the SCORE will be aimed at individuals without cardiovascular disease, aged up to 65 years. The subjects with the disease manifest ATS are considered already high risk and should be treated as such.

The SCORE has a few functions:

highlights the risk of CVD fatal event in the next 10 years in the table, without additional calculations

estimated relative risk, comparing a cell (square of the grid) with any other, in the same category of age,

assess the impact of the improvement of the risk factor (the move from one category to another risk by stopping smoking, lowering total cholesterol, etc.)

highlight the effect of the action of a risk factor in time (increased risk with aging)

THE IMPORTANCE OF THE PROBLEM Cardiovascular disease is the cause of the 48% of deaths (43%

in men and 55% women) in Europe and 42% in the countries of

the European Union, produce more than 4.3 million deaths in

European countries and over 2 million in the 27 countries of

the EU.

A notable proportion of these deaths occurs in relatively young

individuals under 65, and more than 800,000 according to

Europe and over 230,000 in EU countries.

Coronary heart disease (CHD) is the most common cause of

death in Europe, being responsible for 1 in 5 deaths in Europe.

Most epidemiological models used suggest that improvement

and control of risk factors, have had a more marked than in

the control treatment of CVD (here being included major

changes in the treatment of acute coronary syndromes,

hypertension and heart failure, secondary prevention

measures).

PREVENTION STRATEGIES

The work of prevention of CVD has as targets the reduction of mortality and morbidity and increasing hope of life while maintaining or improving quality of life.

There's clear scientific records whitch show that the change in style of life and the control of risk factors in reducing their action, can influence the development and progression of the disease, both before and after producing a clinical event manifest.

PREVENTION STRATEGIES

The World Health Organization (WHO) considers that

a comprehensive action for prevention must include

three components:

Populational strategy - referring to the change in

lifestyle and the environment and addressing social

and economic factors, cultural, determinants of CVD,

is accomplished through the formulation of strategies

and interventions in the community.

Strategy for high-risk population - pressure identified

individuals to high risk and the reduction of risk

factors.

Secondary prevention - prevention of recurrence and

progression of the disease in patients with CVD

clinically manifest.

These three strategies are complementary.

POPULATION STRATEGY

Population Strategy is crucial in

reducing the overall incidence of

cardiovascular disease ,proposing to

reduce the influence of risk factors at

the population level through changes

in lifestyle and social environment,

without the need for individual

medical examination.

Measures of influence on lifestyle

refer to:

• Reducing the number of smokers,

• Encouragement of physical

activity,

• Promotion of healthy eating

habits.

POPULATION STRATEGY

In 2005 the EU adopted a declaration defining characteristics associated with cardiovascular state of health: • No smoking, • Regular physical activity (at least 30 minutes daily) • healthy eating habits, • avoidance of overweight, • blood pressure below 140/90mmHg in patients without diabetes or target organ damage or with multiple risk factors, • Total cholesterol below the threshold of 5 mmol / L (about 200mg/dl). • These characteristics can be summarized as a number: 0-3-5-140-5-3-0

0 - no smoking

3 - 3km or 30 minutes of physical activity daily

5 - fruit and vegetable servings daily

140 - systolic blood pressure less than 140mmHg,

5 - total cholesterol below 5 mmol / l,

3 - LDL cholesterol less than 3 mmol / l,

0 - no overweight or diabetes).

TOTAL RISK ESTIMATION

• Total risk is the probability of a person developing

a fatal cardiovascular event in a defined period of

time.

• Assessment is done by taking into account all risk

factors, not just one.

• The example shown in the table below shows how

a female of 60 years, with a high cholesterol level of

310mg/dl has a 9-fold lower risk for cardiovascular

mortality than a male of the same age, but who

smokes and is hypertensive.

Gender Age Cholester

ol

mmol/l

AP (mm

Hg)

Smoker Risc (%)

F 60 8 120 No 2

F 60 7 140 Yes 5

M 60 6 160 No 8

M 60 5 180 yes 19

STRATEGY FOR HIGH-RISK

POPULATION

• preventive measures for persons at high risk, but otherwise in good health, must become part of clinical practice. Total cardiovascular risk estimation is the first step in prevention measures. • People at high risk are those with: - Multiple risk factors, giving a risk score of ≥ 5% - Significantly increased level of a single risk factor, e.g. BP ≥ 180/110 mmHg or persistent BP ≥ 160/110mmHg, these values should be treated, regardless of the presence of other risk factors, - Total cholesterol ≥ 8 mmol / L (320mg/dL) - LDL-cholesterol ≥ 6 mmol / L (240mg/dL) - Diabetes mellitus (relative risk is 5 for women and 3 for men).

SECONDARY PREVENTION

• Targets patients who have had a cardiovascular event and is considered to be the best cost-effective strategy. • Secondary prevention initially addressed patients with coronary artery disease, particularly those with myocardial infarction or those who were revascularized, both categories being included in rehabilitation program. • Cardiovascular Rehabilitation, with a mainstay at physical activity has been shown to reduce both cardiac mortality, as well as mortality overall. • Patients are relatively few (compared to the population level), easily identifiable and more motivated than those who are asymptomatic. • Secondary prevention suggests counseling regarding lifestyle and pharmacological therapy as the integral part of patient care after a cardiovascular or neurological event.

OBJECTIVES OF SECONDARY PREVENTION:

Smoking cessation

Healthy nutrition

Physical activity: at least 30 minutes of moderate

physical activity daily

Total cholesterol<4,5 mmol/L (175mg/dL) with

option of <4mmol/L (155mg/dL), where feasible

Total LDL-cholesterol <2,5mmol/L (100mg/dL)

with option of < 2 mmol/L (80mg/dL), where

feasible

BP<130/80mmHg.

PHYSICAL ACTIVITY • Lack of physical activity is a major lifestyle problem since childhood. Nowadays, few children practice sports, and most of them become sedentary reaching adulthood. Also, few patients with cardiovascular disease participate in programs with physical exercise, especially when in presence of heart failure. • It is estimated that at least 60% of the world population does not meet the recommended minimum of 30 minutes of moderate physical activity daily • proportion of people who do not perform any kind of physical movement in a week is 25%.

• The risk of developing a cardiovascular disease is at least 1.5 times higher in the inactive people with major impact on the young people, where currently has been registered a marked decrease in physical activity levels at the age group from 12 to 21 years, with a tendency for stabilization at average age (30-64 years) and even improvement at more advanced age.

The combination of excessive caloric intake and insufficient exercise is a contributing factor to the development of metabolic syndrome, with registered epidemic growth in recent years.

The latest report published by the AHA in December 2009 on coronary heart disease and stroke, shows that almost one third (31.9%) of children aged between 2 and 9 years old are overweight or obese.

The study on primary prevention from 2008, which included 513,472 individuals, shows that people who exercise during their free time lower the risk of development of coronary disease or cardiovascular mortality with 27% (for intense physical activity) and with 12% (for moderate activity) in comparison with those with low physical activity, or none at all.

In secondary prevention, reduction of total mortality due to only practicing of physical exercise was assessed at 27% and 31% for cardiac mortality.

PHYSICAL ACTIVITY Weight maintenance or even weight loss for the

overweight,

Has effect on lipid profile by means of increasing, mostly, HDL-cholesterol and lowering the level of triglycerides

Increases insulin sensitivity

Reduces blood pressure

Increases compliance to the measures of influence on other risk factors, thus lowering the incidence of cardiovascular disease and cardiac mortality

Any kind of increase, low to moderate, of the level of effort has positive effects (e.g. usage of stairs instead of elevator).

Everyone can choose the modality of physical activity which seems to be more attractive ( walking, cycling, gardening).

RECOMMENDATIONS

ON PHYSICAL

ACTIVITY

Physical activity may not add

too many years of life,

but more importantly,

adds more life to years remaining

CHILDREN AND ADOLESCENTS

• Each child should be encouraged to perform at least 60,

preferably 90 minutes of physical activity daily, which

significantly increases heart rate , under aerobic

conditions (vigorous intensity at least 3 days a week) ,as

well as muscle and bone strengthening exercises.

• The proposed activities must be adjusted to age, be

pleasant and appealing.

HEALTHY ADULTS

• The European guide on prevention shows that 30 minutes of

moderately vigorous exercise on most days of the week will reduce risk

and increase tonus (physical).

• In practice, this recommendation can be accomplished by performing

at least 30 minutes of moderate physical activity 5 days a week or at

least 20 minutes of vigorous activity three days a week or a

combination of these 2 regimens.

• To the aerobic activity (brisk walk, jogging, dancing, swimming,

games such as basketball), muscle toning exercises should be added at

least 2 days per week (jumping, pushups, squats, lifting weights, elastic

bands, 8 -12 reps per set).

• Additional benefits are obtained by moderate activity of 300 minutes

(5 hours) per week or 150 minutes of vigorous activity or combination

of these two modalities.

ADULT WITH CARDIOVASCULAR DISEASE

• Recommendations on physical training are based on

information obtained from effort tests , whether it is a standard

ECG, or preferably the measurement of gas changes and direct

assesment of oxygen consumption.

• One of the most important components of secondary prevention

is cardiac rehabilitation(rehab).

• The term “Cardiac Rehabilitation” refers to the coordinated,

comprehensive intervention which has as a goal optimization of

physical, psychological and social status of a cardiac patient

with slowing down, stabilization and even regression of

atherosclerotic process, thus reducing morbidity and mortality.

NUTRITION

The relationship between dietary habits and cardiovascular

risk is well established, as demonstrated in several clinical and

epidemiological studies.

General recomandations for subjects with high cardiovascular

risc

nutrients % of energetic

comsumption

Total fats

Saturated fats

Trans acids

Polyunsaturated

N-3

Cholesterol

Fruits and vegetables

Salt

30

10

<2

>10

1g/day

<300g/day

>5 portions/day

<6g/day

LIPIDS

have a major role in the formation of atheromatous plaque.

• The relationship between fat intake and the development of

cardiovascular disease is related to the content of saturated fatty acids,

which increase LDL cholesterol concentration. The main sources are

animal products, processed food industry and certain fats used in

cooking.

• Monounsaturated fatty acid intake is associated with decreased risk of

cardiovascular disease.

• Fatty acids with trans configuration are produced by industrial

hydrogenation of vegetable fats and oils. There is a positive association

between trans acids and cardiovascular morbidity and mortality, which

led to banning of their presence in food in many European countries.

• polyunsaturated acids n-6 and n-3, the main representative of which

is linoleic acid, are derived mainly from vegetable oils and were found

to lower LDL cholesterol and cardiovascular risk compared with intake

of saturated or trans fatty acids.

FRUIT AND VEGETABLES

• are sources of vitamins and fibers, regular intake of which reduces systolic and diastolic blood pressure. • The risk of coronary events is reduced by 7% and stroke by 5% for one serving of fruit and vegetables per day. • In EU countries is recommended consumption of at least 400g/day (leading to prevention of 135,000 cardiovascular disease deaths annually), consumption of 600g daily reduces the risk of cardiovascular disease by 18% and stroke by 11%. • Note that approximately 90% of children in European countries consume fruit and vegetables on daily basis below the recommended amount.

SALT INTAKE

• Approximately 75% of the amount of salt we eat is already in the

food.

• The amount of salt can vary widely within the same product (bread,

for example, can contain from 0.7 to 3 g/100 g of product).

• Reduction of salt intake from food products to 3g (equivalent to

1200mg of sodium) reduces the annual number of new cases of heart

disease by 60,000 to 120,000, of stroke by 32000-66000 and

myocardial infarction with 54000-99000, number of deaths from any

cause being reduced from 44,000 to 92,000.

• The effect is similar to that obtained by reduction of tobacco

consumption by 50%, reduction by 5% of body mass index in obese or

usage of statins in people with low or intermediate risk. Reducing

dietary salt up to 3g/day correlates with lowering of health costs with

10-24 billion annually.

• Currently guidelines for hypertension management based on data

from WHO, recommend daily consumption of only 5g of salt (one

teaspoon).